Overheard a case of difficult airway.

[KLPM]

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Overheard this case over lunch. Thought it might be interesting.

66yo male patient presents for bowel resection for colon cancer.

Hx:

- Recurrent tonsillar tumour
- Unknown TMJ pathology causing extremely limited jaw opening
- Cervical spine arthritis with limited neck movement
- Obese ------> BMI = 42 with a lot of neck fat
- Failed awake fibre-optic intubation previously

I think they ended up doing awake fibre-optic for this guy. Not sure if it was successful.

 

[excalibur]

Retrograde wire is another possibility if one can palpate the cricothyroid membrane

 

[cchoukal]

Retrograde wire is another possibility if one can palpate the cricothyroid membrane

Awake, or are you planning to induce a patient that's got a number of factors suggesting difficult mask ventilation and intubation and then do a procedure (retrograde wire) you and your assistants have likely never done before?

I would plan an awake fiber and do a better job than they did the previous "failed" time. I suspect that the failure was not that they couldn't see the larynx with the bronchoscope, but rather that the patient didn't tolerate the procedure secondary to inadequate topicalization (the source of many threads on this forum).

 

[Idiopathic]

Failure of awake FOI is almost always related to inadequate planning/preparation/topicalization/patient education/skill/patience

with that said, if i did the previous FOI, and felt like i just couldnt get the patient comfortable, I think you could try awake retrograde wire with awake trach as backup

 

[dhb]

Anything awake is fine

 

[KLPM]

Anything awake is fine

Awake bowel resection?

 

[pgg]

Awake, or are you planning to induce a patient that's got a number of factors suggesting difficult mask ventilation and intubation and then do a procedure (retrograde wire) you and your assistants have likely never done before?

It wasn't until after I did a few on cadavers that I realized that the type of wire makes a big difference. The first ones we just took wires from central line kits, too flimsy, almost too short. You want one of the thick long ones the vascular guys use. My small N experience, anyway.

I would plan an awake fiber and do a better job than they did the previous "failed" time. I suspect that the failure was not that they couldn't see the larynx with the bronchoscope, but rather that the patient didn't tolerate the procedure secondary to inadequate topicalization (the source of many threads on this forum).

+1 to that.

My only 'failed' awake FOI since residency was one I aborted. Patient had an airway tumor, came into the ER in resp distress, and once I got a glimpse of the broccoli-like fungating goomba I didn't try to slip past it for fear of making it angry. We did an awake trach instead.

 

[excalibur]

Awake, or are you planning to induce a patient that's got a number of factors suggesting difficult mask ventilation and intubation and then do a procedure (retrograde wire) you and your assistants have likely never done before?

QUOTE]

My plan would be to try and do a better job with AFOI.

If the scenario turned into "everyone has tried AFOI and no one can get it"--Super rare, of course. Then what is Plan B?

Plan B is awake retrograde intubation followed by Plan C awake trach.

 

[sevoflurane]

Look @ the old record. who attempted the FOI? is he/she skilled?
Give a nasal FOI a shot. Might get a better view that way.

Awake trach otherwise. Poking at the tumor for a while isn't advisable in this obese man.

 

[Planktonmd]

An awake fiberoptic done by the right person with good airway anesthesia does not fail.
But if the operator is not skilled with fiberoptic intubation then awake video laryngosscopy of some sort with good airway anesthesia could be a good alternative.

 

[Bostonredsox]

This might be a dumb question but then again I'm a Dumb CC guy not an anesthesiologist. I see danger down the road in this guy. If he has recurrent tumor that I assume is not resectable, probably has OSA based on your description of him, and has failed awake FOI in the past .....why not have ent do a formal trach on him to begin with? I see this man coming to the hospital for one reason or the other, sepsis from uti or PNA, etc, needing a tube and disaster ensuing. In my mind, people that have horribly difficult airways due to an obstruction that cannot be alleviated, especially if it is due to malignancy, plus probable underlying obese necks and OSA should have trachs.

 

[Hamhock]

This might be a dumb question.

I think that is a great question. (but I'm also not trained as an anesthesiologist)

He is certainly going to be coming back to the ED soon, if he survives the current hospitalization.

Additionally, I am not looking forward to extubating this guy or having to emergently intubate him when the unknown but inevitable post-op complication develops.

Any thoughts about consulting ENT from this forum's members?

HH

 

[ssmallz]

Why do people here suggest retrogrades? This is the 2nd airway thread where this has been suggested as a good option. Retrograde sounds decent in theory but the reality is that most of us haven't done one on a live pt and are likely a bit out of practice. If your airway cart is anything like mine the supplies may not be there and I get the feeling it will be much more difficult in real world conditions than the cadaver lab. Awake fiber optic is the first option nasal or oral is fine but then go to an awake trach. Let ENT dude take this airway Bc I would feel way more comfortable letting a guy whose done hundreds of trachs taking this airway then the guy whose done 1 retrograde on a cadaver years ago. Just remember that every failed attempt makes the next one more difficult so why "f" around w/it? This is not an airway you want to mess with so don't try something you may not be comfortable with

 

[DrRobert]

Why do people here suggest retrogrades? This is the 2nd airway thread where this has been suggested as a good option. Retrograde sounds decent in theory but the reality is that most of us haven't done one on a live pt and are likely a bit out of practice. If your airway cart is anything like mine the supplies may not be there and I get the feeling it will be much more difficult in real world conditions than the cadaver lab. Awake fiber optic is the first option nasal or oral is fine but then go to an awake trach. Let ENT dude take this airway Bc I would feel way more comfortable letting a guy whose done hundreds of trachs taking this airway then the guy whose done 1 retrograde on a cadaver years ago. Just remember that every failed attempt makes the next one more difficult so why "f" around w/it? This is not an airway you want to mess with so don't try you may not be comfortable with

👍

How ironic this thread came up today! I'll explain in a minute...

I couldn't agree more. This isn't an oral board scenario where you can simply say "retrograde" and it magically happens.

I trained at a top 5 program, did over 3,000 cases in residency. Now I'm in a busy private practice where we have 45 total ORs. I have never done a retrograde, I've never seen anyone do a retrograde, I don't know anyone who's done a retrograde, and I don't know anyone who's seen someone do a retrograde.

I know we are the airway experts, but part of being an airway expert is knowing when to request a surgical airway. It takes balls to pull the trigger on it, but sometimes it is the best option.

Anyway, just today we had a patient undergoing esophageal dilatation. He had previous oral cancer and essentially had his entire oropharynx removed and radiation therapy. He couldn't really open his mouth... I could hardly get my pinky finger in his mouth. Luckily it was an ENT surgeon doing the case. The plan was simple... MAC and if we have to convert to GEN or we lose the airway, he gets a trach. Nothing else was going to work, including FOI.

Just FYI, we did it under MAC and it took the surgeon 2 hours to get a tiny bougie in the esophagus (which was almost entirely closed by strictures - probably had an opening the size of a pencil eraser). Then he was able to pass the catheter with the balloon attached for the dilatation.

Had this case been attempted by a GI doc... I would have had ENT on standby for a trach. Sometimes you have to swallow your pride and do what's best for the patient. This is not the time to be trying a fukn retrograde.

 

[Idiopathic]

i agree everyone would feel better with a tracheostomy in place but if the patient refuses elective trach, wouldnt you at least consider an awake retrograde intubation? obviously its not first on anybodys list, but its an option.

 

[nimbus]

👍



I trained at a top 5 program, did over 3,000 cases in residency. Now I'm in a busy private practice where we have 45 total ORs. I have never done a retrograde, I've never seen anyone do a retrograde, I don't know anyone who's done a retrograde, and I don't know anyone who's seen someone do a retrograde.

My experience is the same as yours. Only exposure to retrograde was a cadaver workshop in 1995. If retrograde intubation is going to be considered a viable technique, it needs to be taught and practiced on actual patients.

Ps......sounds like your patient needs a g-tube.

 

[Planktonmd]

I am not sure why retrograde intubation keeps getting mentioned either!

 

[TrustMe]

i agree everyone would feel better with a tracheostomy in place but if the patient refuses elective trach, wouldnt you at least consider an awake retrograde intubation? obviously its not first on anybodys list, but its an option.

No!!!!!!!!

Retrograde isn't even on my list.

 

[Idiopathic]

No!!!!!!!!

Retrograde isn't even on my list.

okay well lets just agree its an option. it isnt like anyone is suggesting rectal intubation or anything.

 

[Spinach Dip]

it isnt like anyone is suggesting rectal intubation or anything.

Hmmmm.... But have you seen that recent study that supports it in certain patients who have undergone a radical pulmonary/colonic switch procedure? I hear it's the latest weight-loss fad in France.



Anyway, I know I'm close to the least-experienced person on this board, but my first thought on reading the OP was tracheostomy. Explain carefully to the patient why you want to perform a tracheostomy; if they refuse the elective procedure.... make sure they understand that you must secure their airway somehow.

 

[GoldnLead]

👍

How ironic this thread came up today! I'll explain in a minute...

I couldn't agree more. This isn't an oral board scenario where you can simply say "retrograde" and it magically happens.

I trained at a top 5 program, did over 3,000 cases in residency. Now I'm in a busy private practice where we have 45 total ORs. I have never done a retrograde, I've never seen anyone do a retrograde, I don't know anyone who's done a retrograde, and I don't know anyone who's seen someone do a retrograde.

I know we are the airway experts, but part of being an airway expert is knowing when to request a surgical airway. It takes balls to pull the trigger on it, but sometimes it is the best option.

👍👍👍👍